Medicine: A State of Crisis, A State of Change

Louis Cady, MD

Presented at the 2016 Integrated Medicine for Mental Health Conference

Reston, VA (USA) – September 30th, 2016

Continuing Medical Education Commercial Disclosure Requirement

I, Louis B. Cady, MD, have the following commercial relationships to disclose:•Speaker honoraria received from:

• Immunolaboratories, Great Plains Diagnostic Labs, LABRIX

•Speaker’s bureaus (active) for:• Arbor, Allergan (Aventis), Lundbeck, NEOS, Shire,

Takeda, Vaya Pharma

•Historical data – speaker’s bureau for Arbor, Bristol-Myers Squibb, Celltech, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen, McNeil, Pfizer-Roerig, Sanofi~aventis, Searle, Sepracor, Shionogi, Sunovion, Wyeth-Ayerst

•Distributor – Pharmanex supplements & Biophotonic scanner

Orientation to this lecture

The goal is not to get you depressed, but to open up the possibilities of exciting change and breakthroughs in your practice (which the rest of this conference will cover).

Who this lecture is for

• All docs, all disciplines, all credentials• All nurses and NP’s• All nutritionists• All psychotherapists• Every one here who is or will be a medical

patient at some time.

Attention class!!www.slideshare.net/

lcadymd

Cady Wellness Institute app – Apple “app”store or Google

Android store

Where (else!) to get “the slides”

Everett Napier, an unemployed miner, said he pawned various items while he has been looking for work, including rifles, tools, jewelry and two guitars he used to play at church. 'I just swallowed my pride and quit playing. That's all you can do.' David Stephenson for The Wall Street Journal. November 26, 2013

Chronic Disease Overview• In 2012, half of all adult – 117 million have chronic health conditions.

• COSTS (per year):– Heart dz/stroke $315.4 billion– Smoking $289 billion– Excess alcohol $223.5 billion– Cancer care $157 billion– Diabetes total csot $245 billion– Arthritis $128 billion– Obesity medical costs $147 billionTotal annual cost (est.) $1,504.9 billion, or….

www.cdc.gov/chronicdisease/overview/ - accessed 8/6/2015

$1,504,900,000,000/year

“F as in Fat – How Obesity Threatens America’s Future 2012” Wood Johnson foundation

Current and future IN

obesity rates:

2011 – 25 %

2030 – 49.5%(if BMI reduced 5%)

2030 – 56%

http://healthyamericans.org/report/100/

(c) 2013 Louis B. Cady, M.D. - all rights reserved

“Excess body weight is correlated with excess morbidity and mortality. In particular, Grade 2 or higher obesity (BMI>35) significantly increases the risk of death.”

(www.cdc.gov/nchs/data/hus/hus11_InBrief.pdf)

But what about the PATIENTS?!

http://money.cnn.com/2015/09/22/news/economy/health-insurance/ - accessed 8 15 2016

• Deductibles have increased 67% since 2010• Average deductible for “bronze plan” through

the ACA = > $5700.00

http://www.cbsnews.com/news/the-painful-rise-of-high-deductible-health-insurance/ accessed 08/15/2016

• $90.12 / month * 12 months = $1,081.44 with insurance contribution

• $327 / month * 12 month = $3,924 straight out of pocket

• What about two people with asthma in family?– $7,848 per year

Current statusThe good ole days:•People had jobs•People had insurance•Insurance PAID.•Society was healthier.•Doctors were plentiful.•Your healthcare was essentially “free,” no matter how stupidly you behaved.

Problems:•2001/2008 recessions•Outsourcing•More medical technology•More activism from groups such that “everything must be covered.”•Disastrous public health•More government & PBM’s interference in free market

The RESULTS:•Medical insurance costs more $$$.•Deductible increasing.•Fewer doctors available.

• Doctors are quitting.

• Insurance companies/ government = defacto RATIONING.

•Now, you “gonna have to PAY” for poor health habits, poor nutrition, obesity, smoking, etc.

Likely developments in healthcare, from Tyler Cowen, Average Is Over

• “Just as some poorer people will do without fancy infrastructure, so will others do without advanced health care.”

• “Since we won't be willing to pay for full-benefit Medicare and Medicaid for everyone who will need it, some people will see cut benefits or rationed access to doctors.  Our political system will try to construct that rationing so that voters blame the doctors rather than the politicians, but one way or another rationing will increase.”

“ELIGIBILITY, without AFFORDABILITY and ACCESSIBILITY, is not true health reform.”

- Louis B. Cady, MD

The health of society & the doctors/HCP’s needed to treat it

• Doctors are going to get squeezed. More will quit. (& more patients will be hunting for a doc.)

• Patients’ out of pocket costs are going up with BIG DEDUCTIBLES.

• Americans will have less money to pay for bigger health care costs (e.g. Autism, Alzheimer’s)

• Average people need to do something NOW to maintain health and minimize costs & out of pocket expenses.

GOVERNMENT, BOARD MANDATES FOR MD’S/DO’S

• ICD-10• Second stage of Meaningful Use incentive program (MU2) for Electronic

Health Records• “Sunshine Act”• Updated rules for the Health Insurance Portability and Accountability Act

• Document risk analysis• Comprehensive rules for protected health information

• Physician Quality Reporting System (PQRS)• If not done you will have a 1.5% penalty for all Medicare part B

services• “Maintenance of Certification (MOC)”

Connecticut: United Health Group cuts 2,250 physicians (810 primary care, 1,440 specialists) from its “Medical Advantage” network

One solution to higher costs for medical care if you’re an insurer: fire your doctors so people can’t get to’em.

Another solution to financial outflows from private insurers and Medicaid/Medicare: close hospitals & “reduce beds” so you’re not losing money.

Heck, let’s run out of saline while we’re at it.

“MOC” – IT RHYMES WITH

“CROCK.”

Like many other mandates for the medical profession, physicians also expressed confusion and anxiety about continually changing requirements within the MOC program and a lack of systems support. Low perceived value of the MOC activities and the challenge of fitting them into their already busy schedules results in most participants procrastinating completion as long as possible.

Of all the sections [there are four], the only one that physician participants notes as somewhat useful was phase three, despite the inconvenience of having to complete the examination at a secure testing facility and a lack of feedback on their responses.

http://medicaleconomics.modernmedicine.com/medical-economics/news/moc-needs-revision-physicians-will-recognize-value - accessed 11 17 2014

Patient solutions for cheaper care:don’t go see your doctor

SOURCES OF FRUSTRATION (leading docs to quit or burn out)*:

•The hours and demands of the work•Requirement to interact regularly with insurance companies•Increase in required “clerical duties”•Inefficient electronic medical records•Loss of sense of autonomy •Difficulty maintaining a work/life balance

* sources: RAND Corp, AMA, Mayo Clinic, University of Rochester Medical Center, Stanford University School of Medicine – reported in Chicago Tribune and referenced in Evansville Courier & Press, October 27, 2014 – page 9B

7,288 physician responses45.8% of physicians had at least ONE symptom of

burnout

CONCLUSIONS: “Burnout is more common among physicians than other US workers.”

40% OF DOCTORS ARE BURNED OUT

• TOO MANY BUREAUCRATIC TASKS

• TOO MUCH PAPERWORK• ¼ of time is

spent in non-clinical paperwork.

• Dealing with “checkbox medicine”

Source: Medscape’s 2013 Physician Lifestyle Report cited in “Staying Sane as Medicine Goes Crazy” – July 25, 2014

“Sunshine” in Colorado

Instant replay:Running like a hamster on a wheel

• Working 50 – 60 hours per week• Declining reimbursements; increasing overhead expenses• Hassled by paperwork, Medicare reviewers, prior

authorizations, federal snooping & micro-examination, constant threat of malpractice lawsuits, continued baseline 2% inflation per year and no way to make it up.

• Discriminated against as a profession with invasive monitoring

• Never able to meet all the federal and insurance requirements

WHAT WOULD YOU DO???

Doctors quitting medicine• "Half of primary care physicians in survey would leave

medicine ... if they had an alternative." -- CNN, November 2008

• Suicide* (2004):• 1.41 X for male physicians vs. general pop.• Schernhammer ES, Coldit GZ. Am J Psychiatry. 2004

Dec; 161 (12):2295-302

• Current rate of suicide* – 400 dead docs* per year (in US), 2015. * = specified on death certificate

“Why I Left Medicine: A Burnt-Out Doctor’s Decision to Quit”*

• “It may be dramatic and self-serving to frame my career change as a way to avoid suicide, but I can attest that medicine was not conducive to my health.”

http://commonhealth.wbur.org/2013/10/why-i-left-medicine-a-burnt-out-doctors-decision-to-quit 10/18/2013 – accessed 01/07/2014

Patient complaints = suicidal docs• Increase of moderate – severe anxiety

– 15% if recent complaint vs. 7.3% without (RR 2.08)• Increases moderate - severe depression

– 17% if recent complain vs. 9.5% (RR 1.77)

• Increase suicidal ideation (RR 2.08)• The more severe the complaint, the worse the

mental health effects.

Bourne T, et al. BMJ Open. 2015;5(1):e00687[7,926 doctors in the UK studied]

Physicians – more than 2 X as likely to kill themselves as non physiciansFemale physicians = 3x more likely to kill themselves than male physicians.

REASON: “EHR” requirements. “Would cost too much in his small medical practice.”

Aetna is withdrawing from 11 of 15 states it has health plans in with ACA. - August 16, 2016

December 17, 2013

Are the Best and Brightest Staying in Medicine?

“60% of physicians would not recommend medicine as a career to their children.”

•The Physicians’ Foundationhttp://www.mayorswellnesscampaign.org/wp-content/uploads/2009/05/merritt-hawkins-survey.pdf. Accessed April 3, 2010. Slide and reference courtesy of John Adams, CEO, Cenegenics

So, for self-preservation, just don’t go into medicine.

Might there be some consequences?

“The United States is expected to have a shortfall of nearly 160,000 physicians by 2025 – even as allopathic medical schools have increased their class sizes by 30 percent.”

• Demand will exceed supply {2013-2025}• Demand projected to grow 17%• By 2025, demand will exceed supply by 46,000 –

90,000 doctors.• Shortfalls:

– 12,500 – 31,000 primary care– 28,200 – 63,700 specialists

• 5,100 – 12,300 medical subspecialties• 23,100 – 31,600 surgical specialists• 2,400 = 20,200 other specialists.

Physician Supply & Demand Through 2025: Key Findings

“The physician shortage will persist under every likely scenario.”

From HIS, Inc. study, The Complexities of Physician Supply and Demand: Projections from 2013 to 2025, prepared at request of AAMC.https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf Accessed 8/7/2015

Is Being a Physician (of ANY discipline) – or any other type of health care or mental healthy

worker (clinical or peripheral) still SAFE as a profession??

“But I’m not a [Medical] doctor; I’m not going to have those Problems.”

• Doctors of Chiropractic, Dentistry, Optometry, Naturopathy• mixed fee for service model (at present) and insurance.

• Higher insurance premiums, HIGHER DEDUCTIBLES, & cash-strapped patients.

• Worsening reimbursements• Collateral damage from hospital/clinics closures - service providers

connected with them will lose their jobs.• Paraprofessionals and service support people:

• dieticians, massage/fascia therapists, cosmetologists, servers, maid/janitorial service = declining business, declining tips, declining customer base

http://www.forbes.com/sites/davidwhelan/2010/08/23/whither-chiropractors-a-new-study-shows-many-ditching-the-table/ accessed 9 9 2014

http://www.chiroeco.com/joomla/images/stories/SE_Survey2012.pdf - accessed 9 9 2014

2012 status: “salaries are thus down 28% from last year’s average…and average total compensation fell 13%... From 2011.”

“…an estimated 17.5 percent of newly-licensed RNs leave their first nursing job within the first year and one

in three (33.5%) leave within two years”. http://preventdisease.com/news/14/091014_One-Third-Nurses-Leaving-Jobs-

Losing-Faith-in-Vaccines.shtml accessed 9 11 2014

“80% or greater chance exists for people who make $20/hour or less to be made redundant by smart machines in the foreseeable future.”

-Council of Economic Advisers, February 2016

• The middle class is being inexorably eroded

• “STEM” careers – or management having to do with STEM, are the only safe ones.

• If your job can be done by a machine or a replacement, or outsourced to a cheaper labor market, you are dead.

• Medical care rationing is coming (or is here!); government can’t possibly keep its promises.

Feb 5, 2015

New anesthesiologist on the team…

But what about working people?

(The people who will have to pay the huge deductibles or do

without)

“The Millennials” – any better off?http://w

ww

.nytimes.com

/2015/08/02/opinion/sunday/were-m

aking-life-too-hard-for-m

illennials.html?sm

prod=nytcore-iphone&sm

id=nytcore-iphone-share - accessed 7/31/2015

Is there a way forward?

What can we do about the situation?

A clinical case presentation

A typical Western medicine train wreck.

• 50 year old MWM seen 3/2/2015.• Chief complaint: “It seems like I’m always

sick. […] suggested I give it a try.” • “I go to a regular doctor and it doesn’t seem

to do anything except solve the problem for a short time, and then I’m right back in there again for something or another.”

• History of liver cancer in PGF

Goals for treatment• “have the strength and energy to get out of

bed every morning with an enthusiasm for life.”

• “not get sick so often.” • “get off all of the medications and devices I fell

I need now to get by every day. (Blood pressure, cholesterol, BiPap machine)”

• “strength and energy to play with my 9 year old son.”

Baseline meds:•Atenolol 25 mg in a.m. daily for HTN •Pravastatin 20 mg “daily” during the day. •Depot testosterone 200 mg every 4 weeks. •BiPAP – for three years. •S/P a little anxiety and was treated wth alprazolam 0.25 mg three times daily. “the business thing on Monday a.m.”•ASA 81 mg per day per MD suggestion.Labs at intake:•TSH 3.20 •Fasting glucose 99•BMI = 43.5 kg/m2

Other labs ordered•CORUS, TFT’s (complete), LH, DHEA-S, free and total testosterone, HgBA1C, Glycomark ®, CEA, UA, candida antibodies. Fasting insulin.

• INTERVENTIONS:– Sent to Doctor of Chiropractic for M-

skeletal.– Potent MVI/Multi-mineral, fish oil.– Energy supplement (cordyceps,

pomegranate extract, and panax ginseng)– Colostrum formulation– Gingko – Probiotics– DHEA 25 mg timed release – one every

a.m. and

– Metformin – 500 mg up to twice daily as tolerated.

– Liothyronine – 5 MICROgrams – increase by one per week x 3

– Topical testosterone/stop “q 4 wks.” injxns.DIETARY – 40 grams of protein three times daily.

April 16, 2015• Treatment goals:– Energy and strength

improved– “haven’t been feeling bad at

all.” “Not ill.” – Strength & energy to play

with 9 year old son – increasing.

• STATUS: lost 18 lbs in 6 weeks.

• RX – still on regimen started at intake.

Baseline Labs 3/3/2015:•Suboptimal DHEA-S•Free T3 2.9 {2 – 4.4}•Testosterone 188•Fasting insulin 16.2•25-OH Vit D 18.6 (L)•CORUS testing – 20 (14% risk CAD)•CEA negative•New interventions:

– Clomiphene 50 mg daily– Vitamin D 10K IU per day x 6

weeks, then 7K IU– Start BFL and dumbbells.– Education on low glycemic

eating.

What happened to labs (5/21/2015)?• Thyroid functions (on 5 MICROgrams T3 twice daily) – TSH 2.22 {0.34 – 5.61}– Free T40.7 {0.56 – 1.6}– Free T33.4 {2.0 – 4.4}– Reverse T3 17.6 {9.2 - 24.1}

• Hormones (Rx Clomiphene 50 mg/d, DHEA 50 mg SR a.m.)– Total testosterone 400 {348 – 1197}– Free Testosterone 13.9 {7.2 - 24}– DHEA-Sulfate 601.5* (H) {30.9 – 295.6”; OPTIMAL RANGE –

per Cenegenics is about 500}• * dosing was promptly readjusted

– Estradiol 78 (H) {20 – 70} [ ½ mg Anastrozole added every week)]

Anastrozole ½ mg every week added for just a “touch” of control

June 5, 2015 – 44 lbs lost in 3 months

• “Strength & energy getting better all the time”

• “I have not been sick since I started this.”

• Strength/energy to play with 9 yo. “We’re doing pretty good. It’s gradually getting better. The more weight I lose, the better I feel.”

• Joined gym – going 2x/week and @ 30min on elliptical

June 5, 2015

Per LMD: “You know, he’s jacking with your hormones and that’s dangerous.”

Brain –dead, non-evidenced based “practice guidelines or creativity???

There is inadequate supporting evidence for hair analysis, celiac antibodies, allergy testing (particularly food allergies for gluten, casein, Candida, and other molds), immunologic or neurochemical abnormalities, micronutrients such as vitamin levels, intestinal permeability studies, stool analysis, urinary peptides, mitochondrial disorders (including lactate and pyruvate), thyroid function tests, or erythrocyte glutathione peroxidase studies.”http://www.cdc.gov/ncbddd/autism/hcp-recommendations.html - accessed 8/7/2015

Try reading this with a “practice guideline.”

What can we (personally & professionally) do?

• Live as an example and take care of ourselves, so that we can take care of our patients.

• Rationally examine the cost/benefits of our current practice.

• Decide if our conscience (& our own personal health and psyches) will allow us to survive in the current regimented, bureaucratized, non-evidence based practice of medicine.

• How to learn: “As much as you can.” [Jim Rohn]

• Decide to adopt an INTEGRATIVE approach.

The LAST Slide – “The Challenge” – by Jim Rohn“Let others lead small lives, but not you.

Let others argue over small things,but not you.

Let other cry over small hurts,but not you.

Let others leave their future in someone else’s hands,

but not you.”- Jim Rohn

Contact information and slide resourcesLouis B. Cady, MDCady Wellness Institute4727 Rosebud Lane – Suite FNewburgh, IN 47630 USAOffice (812) 429-0772info@cadywellness.com

Available on Apple “app store” and Google Android store.

www.slideshare.net/lcadymd

Appendix

A primary care doctor would have to work nearly 22 hours each day to meet all of the guidelines for preventive care and chronic disease management for a typical patient panel of 2,500, according to an analysis published in 2009(!).

“People who already feel like they are doing a ton of work, are going to say, 'I can’t do anything more. There’s nothing more to squeeze out of me,” says Marc Tunzi, MD, a family practitioner at Natividad Medical Center in Salinas, California.

http://medicaleconomics.modernmedicine.com/medical-economics/news/4-ethical-dilemmas-facing-physicians accessed 08 11 2014